Principles of Recovery Dr James F Peerless August 2014

Objectives Principles of recovery Overview Handover Pain scores Discharge criteria Day Surgery

Overview

What is Recovery? Specially designated area to recover patients following procedures adjacent to theatres Run by a dedicated team of nurses and ODPs Guidelines exist to ensure patient safety and recognised standards of care There need to be roughly twice the number of bays than theatres. Provision for overflow from ITU/Resus in MAJAX

Recovery General Scavenging Difficult airway trolley Available anaesthetist Emergency call system Drugs Each bay piped oxygen, suction and air. Monitoring equipment –including some invasive monitoring equipment

PACU High standards of monitoring to be maintained until the patient is fully recovered from anaesthesia. Clinical observations must be supplemented by the following monitoring devices: – Pulse oximeter – NIBP The The following must also be immediately available: – Electrocardiograph – Nerve stimulator – Means of measuring temperature – Capnograph

Recovery Standards After general or regional anaesthesia, all patients should be recovered in a specially designated area The anaesthetist must formally hand over the care of a patient to an appropriately trained and registered PACU practitioner. Written criteria for discharge of patients from the PACU should be in place All patients must be observed on a one-to-one basis by an anaesthetist or registered PACU practitioner until they: – have control of their airway – have stable cardiovascular and respiratory systems – are awake and able to communicate. All standards should be applied to all areas in which patients recover after anaesthesia, to include: – anaesthetics given for obstetric, cardiology, imaging and dental procedures, and in psychiatric units.

Handover

Name Age Relevant medical history Allergies and drug history Procedure Type of anaesthetic given Analgesia, Local Infiltration and antiemetics given IV Fluids used and Prescribed Any untoward events during Surgery and Anaesthesia Post-operative instructions

Post-operative Pain

Pain Scores Remember that pain is subjective Simple numerical rating pain scores – (moderate), 7-10 (severe) – 1,2,3 Visual analogue scale FACES

Discharging from PACU

Discharge Criteria General Patients to stay a minimum of 20 minutes Maintain 8+ on SALIM score Vital signs within normal limits for the patient T 36 or above Systems Cardiovascular stability 10 < RR <24 UO satisfactory

Discharge Criteria Surgical Normal wound haemostasis, drain and wound sites satisfactory Reversed from effects of anaesthesia (SALIM 8+) Analgesia and Nausea Pain score <5 Not agitated No PONV At least one set of observations with PCA/epidural operational Appropriate plans for further fluids and analgesia

SALIM 3210 AIRWAYCOUGH OR CRYMAINTAINS CLEAR AIRWAY WITHOUT HOLDING THE JAW HOLDING OF JAW IS REQUIRED HOLDING OF JAW AND OTHER ADJUNCTS REQUIRED BEHAVIOURABLE TO LIFT HEAD CAN OPEN EYES AND SHOW TONGUE SOME NON- PURPOSEFUL MOVEMENTS NO MOVEMENTS CONSCIOUSNESSPATIENT FULLY AWAKE AND ORIENTED AWAKE BUT NEEDS SUPPORT RESPONDS ONLY TO STIMULI UNRESPONSIVE

Common Issues in PACU Pain PONV Other – Altered GCS: Reduced LoC, Agitation – Cardiovascular: Hypotension, ACS – Respiratory: Failure, Hypoxia

Day Surgery

Increasing complexity of day-case procedures Wider range of patients deemed suitable for day-case surgery Anaesthetists need to adopt techniques which allow rapid recovery of the patient, whilst minimising stress and discomfort.

Day-case Recovery Initial Phase – as per Theatre PACU – awake, protective reflexes have returned and pain is controlled Second Phase – Transfer to a day ward – Further recovery and observation of common post- operative problems and emergencies – Nurse-led protocol-based discharge Late Recovery

Discharge Instructions 24 hours post GA: – Dot not drink EtOH, operate heavy machinery, drive Require a supply of adequate post-procedure analgesia suitable to the type of operation Protocol-driven: patients discharged once criteria met.

Discharge Criteria Vital signs stable Orientated to time, place & person Passed urine (if applicable) Able to dress & walk (where appropriate) Oral fluids tolerated (if applicable) Minimal pain Minimal bleeding Minimal nausea ⁄ vomiting Responsible escort present Has carer for 24-h post op Written & verbal post op instructions Knows who to contact in an emergency Dressings supplied Patient copy of GP letter Sick certificate Has take home medication

Discharge Medication

Summary Principles of recovery Overview Handover Pain scores Discharge criteria Day Surgery